Week 9: NURS 171: Health Promotion and Part 2 Fluid, Electrolyte, Acid-Base Balance Flashcards

1
Q

Health Promotion: Levels of Prevention

A
  • primary
  • secondary
  • tertiary
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2
Q

Health Promotion: Levels of Prevention: Primary

A
Prevent/ slow onset of disease
(no illness)
-eating healthy foods
-exercising
-sunscreen
-seat belt
-immunizations
ex: begin with weight bearing exercises as ages
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3
Q

Health Promotion: Levels of Prevention: Secondary

A
Detect and treat illnesses in early stages
-screening activities and education for detecting illness in early stages:
>breast self exam
>testicular exam
>physical examinations
>BP and diabetes screening
>TB test
ex: colonoscopy
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4
Q

Health Promotion: Levels of Prevention: Tertiary

A

Stopping disease progression; return to pre-illness state

  • stopping the disease from progressing
  • returning the individual to pre-illness phase
  • rehabilitation is main intervention
    ex: total hip replacement
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5
Q

Hypovolemia

A

deficient fluid volume; not enough fluid

-fluid volume (and electrolytes) deficient from ECF

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6
Q

Causes for Hypovolemia

A
  • surgery
  • trauma
  • dehydration
  • fluid loss (bleeding)
  • fluid shifts (ascites, into pleural space around lungs)
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7
Q

Signs + Symptoms of Hypovolemia

A
-Dehydration
>thirst
>increased heart rate
>blood vessels constrict to maintain BP
>temperature rises due to inability to cool self through perspiration
>orthostatic hypotension
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8
Q

Alterations in Lab Values in Hypovolemia

A
  • Increased BUN
  • Increased Creatinine Ratio
  • Increased Urine Specific Gravity
  • Elevated Hematocrit
  • Less water related to solid substances (less water than solutes)
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9
Q

Risk for Hypovolemia

A
  • older adults (less muscle, water stored there, less stores)
  • infants
  • children
  • patients with fluid loss
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10
Q

Hypervolemia

A

excessive retention of sodium + water in ECF

too much fluid

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11
Q

Causes of Hypervolemia

A
  • over-hydration (IV, Oral)
  • excess salt intake (retain fluid)
  • kidney or liver disease
  • poor pumping action of the heart
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12
Q

Signs + Symptoms of Hypervolemia

A
  • Increased BP, bounding pulse
  • Pale, cool skin
  • Edema/ Ascites
  • Increased respirations + shallow
  • Crackles
  • Rapid weight gain
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13
Q

Alterations in Lab Values for Hypervolemia

A
  • Decreased BUN
  • Decreased Hematocrit
  • Decreased Urine Specific Gravity
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14
Q

Preventing Hypervolemia

A
  • monitor intake and output

- monitor intravenous and place on electronic pump

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15
Q

White Blood Cells (WBC)

A

(5- 10 x 10^3 mm^3)
primary cell fighting infection and tissue damage
-measured in lab study CBC

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16
Q

Platelets

A

(150,000- 400,000 mm^3)
help the clotting process by sticking to the lining of blood vessels
-measured in the lab study CBC

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17
Q

Laboratory Studies Used to Evaluate Fluid + Electrolyte + Acid-Base Balance

A
  • Complete Blood Count (CBC)
  • Serum Electrolytes
  • Serum Osmolality
  • Urine Osmolality
  • Urinalysis
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18
Q

Lab Study: Complete Blood Count (CBC)

A
  • fluid status is reflected

- measures RBC, Hgb (hemoglobin), HCT (hematocrit), WBC, Platelets

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19
Q

Hemoglobin

A

the iron-containing pigment of red blood cells that carries oxygen from the lungs to the tissues
-measured in the lab study CBC
(Males: 14- 18 g/dL)
(Females: 12-16 g/dL)

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20
Q

Hematocrit (HCT)

A

a measure of the % of the red blood cells in whole blood
-as fluid level decreases, % of cells in ratio to blood increases
-as fluid levels increase, % of cells falls
-measured in the lab study CBC
(Males: 42- 52%)
(Females: 37- 47%)

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21
Q

Lab Study: Serum Electrolytes

A

sodium, potassium, chloride and bicarbonate (electrolytes)

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22
Q

Lab Study: BUN, Creatinine

A

sensitive measures of fluid status + kidney function
(BUN: 10- 31mg/dL)
(Creatinine: Male 0.6- 1.2 mg/dL, Female: 0.5- 1.1 mg/dL)

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23
Q

Lab Studies: Glucose

A

a simple sugar that is the end product of carbohydrate metabolism
(70- 110 mg/dL)

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24
Q

Lab Study: Serum Osmolality

A

measures solute concentration of blood

  • increased means fluid volume deficit
  • decreased means fluid volume excess
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25
Lab Studies: Urine Osmolality
measures solute concentration of urine - increased = fluid volume deficit - decreased = fluid volume excess
26
Lab Study: Urinalysis
measures pH + specific gravity -pH reflects acidosis + alkalosis -specific gravity reflects fluid status (increased specific gravity = fluid levels are low) (decreased specific gravity = fluid is plentiful)
27
Facilitating Fluid Intake
- establish desired intake - develop fluid schedule - fluids may be given by mouth, via a tube, or intravenous - replacement via NG or feeding tube if GI Tract intact - parenteral intake may be needed - set goal for the day (ie. 2500 mL over 24 hours)
28
Facilitating Fluid Restriction
- for a variety of reasons (impaired cardiovascular, liver, or renal function) - determine amount of fluid allowed per shift - usually includes all forms of intake (PO and IV) - inform patients + caregivers of amount allotted - offer ice chips + frequent oral hygiene for comfort - keep liquids away from bedside
29
Intravenous Solutions
-Isotonic -Hypotonic -Hypertonic (classified according to how they compare to the osmolality of blood serum (275-290 mOsm/Kg))
30
Isotonic Fluids
(250-375 mOsm/Kg) -remain in the blood vessels Ex: 0.9% NaCl= normal saline, lactated ringers
31
Hypotonic Solution
(< 250 mOsm/Kg) -pull water out of blood vessels into cells Ex: D5W and 0.45 NaCl = half normal saline
32
Hypertonic Soluton
``` pulls water into the blood vessels -volume expanders (if i am putting more solutes, the water is going to come to the blood vessels) Ex: -D5 0.9% NaCl -D5 0.45% Nacl -D5RL ```
33
8 Blood Types
``` 4 Groups: A, B, AB, O -A (+ or -) -B (+or -) -AB (+ or -) -O (+ or -) >inherit from parents >must receive only blood that is compatible with own blood group -Rh factor determines if you are (+) or (-); present (+), not present (-) ```
34
Cross-matching
- once blood passed initial screen test - occurs between donated blood + potential donors blood - identifies minor antigens that will affect the compatibility of the donor blood in the recipient - RBC from donor are mixed with plasma from recipient - if testing shows the risk of transfusion is low = safe to transfuse
35
People with Rh (+) may receive
Rh (+) or Rh (-) blood
36
People with Rh (-) may only receive
Rh (-) blood
37
Blood type O (-) is considered
a universal donor
38
Blood Type AB (+) is considered
a universal recipient
39
Blood Typing + Cross-matching Screen Tests
Hep B, Hep C, HIV, West Nile, Syphillis
40
Blood Products
- Whole Blood - Red Blood Cells (RBC) - Plasma - Platelets - White Blood Cells (WBC)
41
Blood Products: Whole Blood
contains RBC, WBC and platelets suspended in plasma
42
Blood Products: Red Blood Cells
-removed from whole blood for transfusion -RBC that are transfused (packages RBCs or PRBCs) can raise clients hematocrit (HCT) + hemoglobin (Hgb) level while minimizing an increase i volume (most common transfusion)
43
Blood Products: Plasma
- liquid portion of blood - makes up 55% of blood volume - includes albumin, clotting factors, immune globulins (may be transfused as a whole or be separated)
44
Blood Products: Platelets
help the clotting process by sticking to the lining of blood vessels (150,000- 400,000)
45
Blood Products: White Blood Cells
for clients with infections not responsive to antibiotic therapy (5- 10 x 10^3 mm^3)
46
Initiating a Transfusion
-verify written prescription for the blood -identify patient -obtain vital signs prior to initiating >if temp elevated, notify healthcare provider -inspect intravenous site for patency + size -identify blood product -inspect IV site
47
Transfusion Reaction
- ensure to follow all safety checks + protocols - start transfusion slow - remain with patient for first 5 minutes - assess again at 15 minutes
48
Examples of Transfusion Reactions
- allergic - bacterial - febrile - hemolytic - circulatory overload
49
Transfusion Reaction: Allergic
``` allergy to blood being transfused -Signs + Symptoms: >flushing >itching >wheezing >urticaria (hives) >anaphylaxis ```
50
Transfusion Reaction: Allergic Nursing Responsibilities
- stop transfusion - replace with saline solution - notify physician immediately - administer prescribed antihistamine
51
Transfusion Reaction: Bacterial
``` contamination of blood -Signs + Symptoms: >fever >chills >vomiting >diarrhea >hypertension ```
52
Transfusion Reaction: Bacterial Nursing Responsibilities
- stop transfusion - replace with saline solution - notify physician immediately - administer prescribed antibiotics - treat symptoms
53
Transfusion Reaction: Febrile
``` temperature elevation due to sensitivity to WBCs, plasma protein or platelets -Signs + Symptoms: >fever >chills >warm, flushed skin >aches ```
54
Transfusion Reaction Febrile Nursing Responsibilities
- stop transfusion - replace with saline solution - notify physician immediately - treat symptoms
55
Transfusion Reactions: Hemolytic
``` destruction of RBCs as a result of infusing incompatible blood -Signs + Symptoms: >fever >chills >dyspnea >chest pain >tachycardia >hypotension >can be fatal ```
56
Transfusion Reactions Hemolytic Nursing Responsibilities
- stop transfusion - replace with saline solution - notify physician immediately - send blood including tubing and filters along with sample of venous blood and first voided urine to lab for analysis - treat shock
57
Transfusion Reaction: Circulatory Overload
``` administering too great volume or too rapidly -Signs + Symptoms: >persistent cough >crackles (lung sound) >hypertension >distended neck veins ```
58
Transfusion Reaction Circulatory Overload Nursing Responsibilities
- slow or stop transfusion - monitor vital signs - place client upright - notify physician
59
Guidelines for Measuring Intake
- identify factors that can affect fluid intake - measure intake: oral (liquids or those that melt at room temp), intravenous fluids, enteral or parenteral nutrition fluids - record info per policy - document in mL
60
Guidelines for Measuring Output
- urine output - empty wound drains or other devices + measure volume - record per policy - be aware of insensible losses that can not be measured (wound dressing, perspiration)